Healthcare Provider Details

I. General information

NPI: 1114398815
Provider Name (Legal Business Name): SERGIO GERARDO TEJADA P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2267 DRUMMOND ST
RIVERSIDE CA
92506-1533
US

IV. Provider business mailing address

2267 DRUMMOND ST
RIVERSIDE CA
92506-1533
US

V. Phone/Fax

Practice location:
  • Phone: 951-236-5356
  • Fax:
Mailing address:
  • Phone: 951-236-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: